Patella bone plate and methods of fixation

ABSTRACT

A patella fracture fixation system includes a peripheral rim bone plate that is configured to be implanted along a parapatellar lateral approach. The bone plate can configured to minimize disruption of blood supply to the patella. The bone plate can be augmented with a Krackow suture pattern to assist in stabilization of a comminuted inferior pole.

CROSS-REFERENCE TO RELATED APPLICATIONS

This claims the benefit of U.S. Patent Application Ser. No. 62/214,827filed Sep. 4, 2015, the disclosure of which is hereby incorporated byreference as if set forth in its entirety herein.

BACKGROUND

Patella fractures represent approximately 1% of all fractures and can bedebilitating injuries resulting in extensor mechanism weakness,decreased knee range of motion, anterior knee pain, and degenerativepatellofemoral arthritis. The limited soft tissue coverage andimportance of the patella in knee extensor mechanism function has madeoperative treatment of these injuries challenging.

Historically, patellar fractures were treated non-operatively, which wasthought to allow for adequate pain relief and partial restoration ofextensor mechanism function. However, as surgical knowledge andtechnique has advanced, management of these injuries has evolved fromnon-operative care or patellectomy to anatomic reduction and internalfixation with a goal of osseous union.

Today, a non-operative treatment course can be recommended fornon-displaced fractures of the patella, particularly when the fractureis non-displaced, the articular surface is not disrupted, and theextensor mechanism is intact. However, a disruption of the articularsurface of as little as 2 mm or separation of bone fragments by aslittle as 3 mm is conventionally associated with an unacceptable risk ofunsuitable bone healing. Additionally, patients with patella fracturesoften have concurrent retinacular tears that can result in fracturedisplacement and disruption of the extensor mechanism. Further, becauseof the important role of the patella in maintaining normal kinematics ofthe knee, operative management is considered to be the treatment ofchoice for patella fractures when patellar bone fragments are displaced,or the articular surface is disrupted.

One construct commonly used for the operative fixation of patellafractures is a tension band. In particular, an anterior tension band isapplied by passing wires or braided cables or sutures behind previouslyimplanted K-wires at the superior and inferior poles, crossing them, andtwisting the ends to create a figure-eight pattern. Finally, a wire orbraided cable is wrapped circumferentially around the patella directlyon bone at a location anterior to the previously placed wires, and istightened by twisting. A modification of this technique can be performedby replacing the K-wires with cannulated screws, such that a wire orbraided cable or suture can be passed through the cannulated screws tocreate the anterior tension band with a figure-eight configuration,followed by application of a cerclage wire directly on the circumferenceof the patella.

While tension band constructs are the most common method of fixation,anterior knee pain, failure of the construct, and functional limitationwith tension band fixation have all been reported. Further, thistechnique often fails to address inferior pole comminution commonly seenin fractures of the patella.

More recently, biomechanical studies have shown an advantage to fixationof patella fractures with plating constructs as opposed to tension bandfixation. While various different patella plating constructs in usetoday can achieve satisfactory fracture reductions, the ultimateoutcomes are often ineffective and clinically poor. In particular,despite reliable fracture healing and restoration of the extensormechanisms, outcomes often remain unacceptable with conventiontechniques. A common misconception among surgeons is that patientsrecovering from patella fracture fixation mostly do well. However, thisis likely because patients are not followed long enoughpost-operatively. Anterior knee pain after patellar fracture fixation isa common complaint during daily activity. Potential causes includepatella baja, extensor mechanism malalignment, articular injury andposttraumatic arthritis, painful implants, or avascular necrosis. Thisanterior knee pain leads to limited rehabilitation and functionalimpairment.

Still another surgical option is to perform a partial or totalpatellectomy, though these procedures are typically reserved for extremecases such as open injuries. Patellectomy procedures produce a high riskfor creating patella baja, and bone-to-bone healing is preferred overtendon-to-bone healing. Also, a partial patellectomy procedure is likelyto disrupt the main blood supply to the patella as it enters theinferior pole.

In other instances of an isolated inferior pole fracture that does notinclude the articular surface, fracture repairs are sometimes beperformed with what are commonly known as Krackow sutures. Inparticular, Krackow sutures are placed on the medial and lateral aspectsof the patellar tendon, and retrograde drill holes are created from theinterior pole to the superior apex of the patella. The sutures are thenpassed through the drill holes and tied over the superior bony edge ofthe patella.

SUMMARY

In one aspect of the present disclosure, a bone plate is provided forfixation to a fractured patella. The bone plate can include a bone platebody that defines an inner surface configured to face the patella, andan outer surface opposite the inner surface. The bone plate body caninclude a base that is configured to surround a lateral portion of acircumferential rim of the patella. The base can include an intermediatesection, a first outer section that extends substantially in a firstselect longitudinal direction from the intermediate section, and asecond outer section that extends from the intermediate sectionsubstantially in a second select longitudinal direction opposite thefirst longitudinal direction. The bone plate body can further include anouter portion that extends from the base in a first select lateraldirection substantially perpendicular to each of the first and secondselect longitudinal directions. Each of the intermediate section, thefirst outer section, the second outer section, and the outer portion candefine a respective at least one bone fixation hole that extends throughthe bone plate body from the outer surface to the inner surface.

BRIEF DESCRIPTION OF THE DRAWINGS

The following detailed description will be better understood when readin conjunction with the appended drawings, in which there is shown inthe drawings example embodiments for the purposes of illustration. Itshould be understood, however, that the present disclosure is notlimited to the precise arrangements and instrumentalities shown. In thedrawings:

FIG. 1A is a top plan view of a patella bone plate constructed inaccordance with one embodiment, shown in a flat configuration;

FIG. 1B is a perspective view of the patella bone plate illustrated inFIG. 1A, shown in a contoured configuration;

FIG. 1C is another perspective view of the patella bone plateillustrated in FIG. 1B, shown in the contoured configuration;

FIG. 2A is a top plan view of a patella bone plate constructed inaccordance with another embodiment, shown in a flat configuration;

FIG. 2B is a perspective view of the patella bone plate illustrated inFIG. 2A, shown in a contoured configuration;

FIG. 2C is another perspective view of the patella bone plateillustrated in FIG. 2B, shown in the contoured configuration;

FIG. 3A is a schematic perspective view of a patient's knee, shown aftera parapatellar lateral approach incision and completion of aparapatellar arthrotomy;

FIG. 3B is a schematic perspective view of the knee illustrated in FIG.3A, shown after implantation of temporary fixation elements into bonefragments of the patella;

FIG. 3C is a schematic perspective view of the knee illustrated in FIG.3B, shown after reduction of the bone fragments and angular articulationof the patella;

FIG. 4A is a schematic perspective view of the knee illustrated in FIG.3C, showing placement of the bone plate illustrated in FIG. 1A againstthe patella, and lateral fixation elements aligned for insertion throughthe bone plate and into the patella;

FIG. 4B is a schematic perspective view of the knee illustrated in FIG.4A, showing the lateral fixation elements inserted through the boneplate and into the patella;

FIG. 4C is a schematic perspective view of the knee illustrated in FIG.4B, showing a superior fixation element aligned for insertion throughthe bone plate and into the patella;

FIG. 4D is a schematic perspective view of the knee illustrated in FIG.4B, showing the superior fixation element inserted through the boneplate and into the patella;

FIG. 4E is a schematic perspective view of the knee illustrated in FIG.4D, shown with the superior fixation element inserted through the boneplate and into the patella, and further showing an inferior fixationelement aligned for insertion through the bone plate and into thepatella;

FIG. 4F is a schematic perspective view of the knee illustrated in FIG.4E, shown with the inferior fixation element inserted through the boneplate and into the patella;

FIG. 4G is a schematic perspective view of the knee illustrated in FIG.4F, showing a pair of anterior fixation elements aligned for insertionthrough the bone plate and into the patella;

FIG. 4H is a schematic perspective view of the knee illustrated in FIG.4G, shown with the anterior fixation elements inserted through the boneplate and into the patella; and

FIG. 5 is a schematic perspective view of the knee illustrated in FIG.4G, shown augmented with Krackow sutures attached to the patellar tendonand the bone plate.

DETAILED DESCRIPTION

The present disclosure is related to a patella bone plate and methods ofwith fixing the bone plate to the patella. It has been discovered thatthe bone plate and associated methods of fixation provide for stabilityacross multiple fracture fragments. The bone plate and associatedmethods can also address inferior pole comminution. Further, the boneplate can be fixed to the patella without compromising a vascular supplyto the patella. The vascular supply that is avoided is currentlybelieved to be the primary vascular supply to the patella.

A bone plate 20 will now be described with reference to FIGS. 1A-1C, itbeing appreciated that the description of the bone plate 20 illustratedin FIGS. 1A-1C also applies to the bone plate 20 illustrated in FIGS.2A-2C unless otherwise indicated. The bone plate 20 is configured forfixation to the patella bone. In one example, the bone plate 20 can beconfigured as a mesh cage 22 that is configured to surround the lateralend of the circumferential or peripheral rim of the patella as well as aportion of the anterior cortex of the patella. Thus, as will beappreciated from the description below, the bone plate 20 is configuredto provide fixation of a patella after fracture reduction so as tomaintain alignment of the articular surface.

The bone plate 20 includes a bone plate body 24 that defines an innersurface 24 a configured to face the patella, and an outer surface 24 bopposite the inner surface 24 a. The bone plate 20 further includes aplurality of fixation holes 26 that extend through the bone plate body24 from the outer surface 24 b to the inner surface 24 a. In oneexample, the bone plate body 24 includes a plurality of eyelets 28 andlinks 30 that are connected between adjacent ones of the eyelets 28. Thefixation holes 26 can extend through the eyelets 28 from the outersurface 24 b to the inner surface 24 a. In particular, the fixationholes 26 can extend through the eyelets 28 along respective central axes25. One or more up to all of the links 30 can extend linearly from andto adjacent ones of the eyelets 28. Alternatively or additionally, oneor more up to all of the links 30 can define bent regions betweenadjacent ones of the eyelets 28 so as to provide for linear distanceadjustment between the corresponding adjacent ones of the eyelets 28.The links 30 and the eyelets 28 can be monolithic with each other.Alternatively, the links 30 and the eyelets 28 can be secured to eachother using any attachment technique as desired. The bone plate 20 canbe a titanium bone plate, a stainless steel bone plate, or anyalternative suitable biocompatible made as desired that possesses therequisite strength for patella fixation.

As is described in more detail below with respect to FIGS. 4A-4G, thefixation holes 26 are configured to receive a respective fixationelement that is configured for insertion through the fixation hole 26and into the underlying patella so as to fix the bone plate 20 to thepatella. Thus, a fixation system can include the bone plate 20 and thefixation elements. It should be appreciated, of course, that the boneplate 20 can be alternatively configured as desired so as to define thebone plate body and a plurality of fixation holes 26 that extend throughthe bone plate body 24 from the outer surface 24 b to the inner surface24 a.

The plate body 24 can include any number of eyelets 28 as desired, itbeing appreciated that a greater number of eyelets allows for greaterflexibility in the positioning of fixation elements to be driven intothe patella. In this regard, it is recognized that patella fractures canbe significantly comminuted, and that it may be desirable to drive thefixation elements into select ones of the bone fragments. By including alarge number of eyelets 28, the fixation element can be aligned with adesired bone fragment.

With continuing reference to FIGS. 1A-1C, the bone plate 20 has a lengththat extends along a longitudinal direction L, a height that extendsalong a lateral direction A that is oriented substantially perpendicularwith respect to the longitudinal direction L, and a thickness thatextends along a transverse direction T that is oriented substantiallyperpendicular to each of longitudinal direction L and the lateraldirection A. Unless otherwise indicated, the longitudinal direction asused herein can include the longitudinal direction L and directionswithin 45 degrees of the longitudinal direction L. Similarly, unlessotherwise indicated, the lateral direction as used herein can includethe lateral direction A and directions within 45 degrees of the lateraldirection A. Similarly, unless otherwise indicated, the transversedirection as used herein can include the transverse direction T anddirections within 45 degrees of the transverse direction T.

When the bone plate 20 is in a flat configuration illustrated in FIG.1A, the length and the height can be coplanar with each other. When thebone plate 20 is in a contoured configuration illustrated in FIGS.1B-1C, the length and thus the longitudinal direction L can be curved ina first respective direction of curvature such that the inner surface 24a defines a concavity. Similarly, and the height and thus the lateraldirection A can be curved in a second respective direction of curvaturethat is different than the first respective direction of curvature suchthat the inner surface 24 a defines a concavity. The first and seconddirections of curvature can be substantially perpendicular to eachother. In one example, the curvatures of the length and the height canbe linear and thus can lie in respective first and second planes. Thefirst and second planes can be substantially orthogonal to each other.In another example, the curvatures can be non-linear from eyelet toeyelet. It should thus be appreciated that the curvatures of the lengthand height can be shaped as desired such that the inner surface 24 a iscontoured to substantially match the contour of the patella.

The bone plate body 24, and thus the bone plate 20, can include a base32 that extends along the longitudinal direction L. The base 32 isconfigured to attach to a peripheral rim of a patella, as will bedescribed in more detail below. Thus, the bone plate can also bereferred to as a patella peripheral rim bone plate. The bone plate body24, and thus the bone plate 20, includes a plurality of bone fixationholes 26 that extend through the base 32 along the transverse directionT from the outer surface 24 b to the inner surface 24 a. For instance,the base 32 can include a plurality of eyelets 28 and links 30 connectedbetween adjacent ones of the eyelets 28. In particular, the base 32 caninclude at least one row 34 of eyelets 28 that are spaced from eachother along the longitudinal direction L. Thus, the at least one row 34can be said to be oriented along the longitudinal direction L. The base32 can define an intermediate section 32 a, a first outer section 32 bthat extends out from a first side of the intermediate section 32 a, anda second outer section 32 c that extends out from a second side of theintermediate section 32 a that is opposite the first side. Thus, theintermediate section 32 a can be disposed between the first outersection 32 b and the second outer section 32 c. The first outer section32 b is configured to be fixed to the patella on the boney edge of thesuperior pole of the patella under (or posterior of) the quadricepstendon. The second outer section 32 b is configured to be secured to thenon-articulating inferior pole of the patella under (or posterior of)the patellar tendon. Thus, the first outer section 32 b can define asuperior extension of the bone plate 20 when the bone plate 20 isconfigured and aligned for attachment to the patella. Similarly, thesecond outer section 32 c can define an inferior extension of the boneplate when the bone plate 20 is configured and aligned for attachment tothe patella.

The fixation holes 26 of the at least one row 34 can be at leastpartially aligned with each other along the longitudinal direction L.For instance, the fixation holes 26 of the at least one row 34 can bepartially aligned with each other along the longitudinal direction L. Inone example, the fixation holes 26 of the at least one row 34 can bealigned with each other along the longitudinal direction L. The centralaxes 25 of the fixation holes 26 that are said to be aligned along adirection can be inline with each other along that direction.Alternatively or additionally, the link 30 that is connected between theeyelets 28 of adjacent fixation holes 26 that are said to be alignedalong a direction can extend along the direction from and to adjacentones of the eyelets 28 that are said to be aligned with each other.Alternatively or additionally still, the link 30 that is connectedbetween the eyelets 28 of adjacent fixation holes 26 that are said to bealigned along a direction can extend along the direction from and toadjacent ones of the eyelets 28 that are said to be aligned with eachother. Alternatively or additionally still, the link 30 that isconnected between the eyelets 28 of adjacent fixation holes 26 that aresaid to be aligned along a direction can extend from one location of afirst one of the eyelets 28 at a first location, and can extend from asecond location of a second one of the eyelets 28. The first and secondlocations can be aligned with each other along the direction.

Further, central axes 25 of the fixation holes 26 that are said to be atleast partially aligned along one of the longitudinal direction L andthe lateral direction A can be offset from each other along the other ofthe lateral direction A and the longitudinal direction L such that aplane defined by the transverse direction T and the one of thelongitudinal direction L and the lateral direction A can pass throughthe fixation holes 26 of adjacent eyelets that are said to be partiallyaligned along the one of the longitudinal direction L and the lateraldirection A. Alternatively or additionally, the link 30 that isconnected between the eyelets 28 of adjacent fixation holes 26 that aresaid to be partially aligned along a direction can extend along a seconddirection that defines an angle with respect to the direction of partialalignment that is 45 degrees or less. Alternatively or additionallystill, the link 30 that is connected between the eyelets 28 of adjacentfixation holes 26 that are said to be partially aligned along adirection can extend along a second direction that defines an angle withrespect to the direction of partial alignment that is 45 degrees or lessfrom and to adjacent ones of the eyelets 28 that are said to bepartially aligned with each other. Alternatively or additionally still,the link 30 that is connected between the eyelets 28 of adjacentfixation holes 26 that are said to be partially aligned along adirection can extend from one location of a first one of the eyelets 28at a first location, and can extend from a second location of a secondone of the eyelets 28. The first and second locations can be alignedwith each other along a second direction defines an angle with respectto the direction of partial alignment that is 45 degrees.

In one example, the at least one row 34 of the base 32 can include firstand second rows 34 a and 34 b of eyelets 28, the rows spaced from eachother along the lateral direction A. In this regard, the longitudinaldirection L can define a row direction, and the lateral direction A candefine a column direction. In one example, the second row 34 b can bespaced from the first row 34 a in a first select lateral direction.Thus, the first row 34 a can be spaced from the second row in a secondselect lateral direction that is opposite the first select lateraldirection. When the plate 20 is oriented and configured for fixation tothe patella, the first select lateral direction can be defined by one orboth of the anatomical medial direction and the anatomical anteriordirection. Thus, the second row 34 b can be spaced one or both ofmedially and anteriorly from the first row 34 a when the bone plate 20is configured and aligned for attachment to the patella.

The first and second rows 34 a and 34 b can be spaced from each otheralong the lateral direction A. The eyelets 28 of the first row 34 a canbe at least partially aligned with respective ones of the eyelets 28 ofthe second row 34 b along the lateral direction A. For instance, theeyelets 28 of the first row 34 a can be partially aligned withrespective ones of the eyelets 28 of the second row 34 b along thelateral direction A. In one example, the eyelets 28 of the first row 34a can be aligned with respective ones of the eyelets 28 of the secondrow 34 b along the lateral direction A. In another example, the eyeletsof the first and second row 34 a and 34 b can be staggered with respectto each other along the longitudinal direction L. The first and secondrows 34 a and 34 b of eyelets can be oriented substantially parallel toeach other. It is recognized that first and second rows 34 a and 34 b ofeyelets 28 allow for positional flexibility along both the longitudinaldirection L and the lateral direction A of bone fixation elements thatpass through the eyelets 28 of the base 32 and into the anterior rim ofthe patella, as will be described in more detail below. Thus, the base32 is configured to be fixed to the lateral rim of the patella atlocations that are offset from each other both along the longitudinaldirection L and the lateral direction A. For instance, selection of oneof the first and second rows 34 a and 34 b allows for positionalflexibility along the lateral direction A. Selection of one of theplurality of fixation holes 26 of a given one of the rows 34 a and 34 ballows for positional flexibility along the longitudinal direction L.Further, one or both of the rows 34 a and 34 b can be angulated alongthe superior and inferior portions of the rim of the patella so as toprovide for additional positional flexibility along the lateraldirection A.

The first and second rows 34 a and 34 b can include the same number ofeyelets 28 or a different number of eyelets 28. In one example, thefirst row 34 a has a greater number of eyelets than the second row 34 b.The eyelets 28 of the first row 34 a can be equidistantly spaced fromeach other along the longitudinal direction L a first distance. Further,the eyelets 28 of the second row 34 b can be equidistantly spaced fromeach other along the longitudinal direction L a second distance. Thesecond distance can be equal to the first distance. Alternatively, thesecond distance can be greater than or less than the first distance. Theeyelets 28 of the second row 34 b can be offset from the eyelets 28 ofthe first row 34 a a respective distance along the lateral direction Athat can be equal to one or both of the first and second distances.Alternatively, the eyelets 28 of the second row 34 b can be offset fromthe eyelets 28 of the first row 34 a a respective distance along thelateral direction A that can be different than each of the first andsecond distances.

The first row 34 a can define a first longitudinal end 37 a, a secondlongitudinal end 37 b that is opposite the first longitudinal end 37 a,and a middle segment 37 c disposed between the first and secondlongitudinal ends 37 a and 37 b. The first longitudinal end 37 a can besaid to be spaced from the second longitudinal end 37 b in a firstselect longitudinal direction. Similarly, the second longitudinal end 37b can be said to be spaced from the first longitudinal end 37 a in asecond select longitudinal direction opposite the first selectlongitudinal direction. The first longitudinal end 37 a can be definedby the first outer section 32 b. The second longitudinal end 37 b can bedefined by the second outer section 32 c. The middle segment 37 c can bedefined by the intermediate section 32 a. When the bone plate 20 isoriented and configured for fixation to the patella, the first selectlongitudinal direction can be at least partially defined by the superiordirection. Thus, when the bone plate 20 is oriented and configured forfixation to the patella, the first select longitudinal direction can beat least partially defined by the inferior direction.

Similarly, the second row 34 b can define a first longitudinal end 38 a,and a second or middle segment 38 b disposed adjacent the firstlongitudinal end 38 a. It is also envisioned that the second row caninclude a second longitudinal end that is opposite the firstlongitudinal end 38 a, such that the middle segment 38 b disposedbetween the first longitudinal end 38 a and the second longitudinal end.The first longitudinal end 38 a can be spaced from the secondlongitudinal end in the first select longitudinal direction. The secondlongitudinal end can be spaced from the first longitudinal end 38 a inthe second select longitudinal direction. The first longitudinal end 38a can be defined by the first outer section 32 b. The secondlongitudinal end can be defined by the second outer section 32 c. Themiddle segment 38 b can be defined by the intermediate section 32 a.

The first row 34 a defines a first longitudinal length fromlongitudinally outermost ends of the first row 34 a. The second row 34 bdefines a second longitudinal length that can extend from longitudinallyopposed outermost end of the second row 34 b. The first longitudinallength can be greater than the second longitudinal length.Alternatively, the second longitudinal length can be greater than thefirst longitudinal length. Alternatively, the first longitudinal lengthcan be substantially equal to the second longitudinal length.Accordingly, as will be appreciated from the description below, thefirst row 34 a is configured to reach further around the superior andinferior poles of the patella than the second row 34 b.

In one example, the first longitudinal end 37 a of the first row 34 acan be disposed outboard of the first longitudinal end 38 a of thesecond row 34 b along the longitudinal direction L, and in particular inthe first select longitudinal direction. In particular, the firstlongitudinal end 37 a can be offset from the first longitudinal end 38 aa first offset distance. The second longitudinal end 37 b of the firstrow 34 a can be disposed outboard of the second row 34 b along thelongitudinal direction L, and in particular in the second selectlongitudinal direction. In particular, the second longitudinal end 37 bcan be offset from the second row 34 b a second offset distance. In oneexample, the first offset distance can be less than the second offsetdistance. Thus, the first longitudinal end 37 a can include fewereyelets 28 than the second longitudinal end 37 b that are disposedlongitudinally outboard of the second row 34 b. Alternatively, the firstand second longitudinal ends 37 a and 37 b can include an equal numberof eyelets 28 that are disposed longitudinally outboard of the secondrow 34 b. Alternatively still, the second longitudinal end 37 b caninclude fewer eyelets 28 than the first longitudinal end 37 a that aredisposed longitudinally outboard of the second row 34 b. Thus, it shouldbe appreciated, of course, that the first offset distance can be greaterthan the second offset distance. Alternatively still, the first offsetdistance can be substantially equal to the second offset distance.

It should be appreciated that while the base 32 has been described inaccordance with one embodiment, and that numerous alternative designsare envisioned suitable for implantation as described in more detailbelow. For instance, while the base 32 has been described as includingfirst and second rows 34 a and 34 b, the base 32 can include any numberof rows as desired, greater than or equal to one. The first row 34 a candefine an outer boundary of the bone plate with respect to the secondselect lateral direction. It is further envisioned that the base 32 canbe constructed without any rows but still including the first outersection 32 b configured for fixation to the superior boney edge of thesuperior patella under (or posterior of) the quadriceps tendon, and thesecond outer section 32 b configured to be secured to thenon-articulating distal pole of the patella under (or posterior of) thepatellar tendon.

With continuing reference to FIGS. 1A-1C, the bone plate body 24, andthus the bone plate 20, can further include an outer portion 40 thatextends from the base 32 along the lateral direction A. The outerportion 40 can be monolithic with the base 32. Alternatively, the outerportion 40 can be fastened to the base 32 in any manner as desired.During use, when the base 32 surrounds a portion of the patella rim, theouter portion 40 is configured to extend medially over the anteriorcortical surface of the patella. For instance, the base 32 can at leastpartially surround the lateral half of the patella rim. Thus, it shouldbe appreciated that the base 32 can be contoured to fit against thepatella rim, and the outer portion 40 can be contoured to fit againstthe anterior cortical surface of the patella. The bone plate body 24,and thus the bone plate 20 includes a plurality of bone fixation holes26 that extend through the outer portion along the transverse directionfrom the outer surface 24 b to the inner surface 24 a. Thus, the patellaperipheral rim bone plate 20 can be further configured to be fastened tothe anterior surface of the patella.

For instance, the outer portion 40 can include a plurality of eyelets 28and links 30 connected between adjacent ones of the eyelets 28. Inparticular, the outer portion 40 can include at least one column 42 ofeyelets 28 that are spaced from each other along the lateral directionA. Thus, the at least one column 42 can be said to be oriented along thelongitudinal direction A. The outer portion 40 can define an outerproximal end 40 a, an outer intermediate section 40 b, and an outerdistal end 40 c. The outer intermediate section 40 b can be disposedbetween the outer proximal end 40 a and the outer distal end 40 c. Theouter proximal end 40 a can extend out from the base 32. The outerportion 40 can terminate at the outer distal end 40 c which can be afree end. The outer portion 40 can thus be cantilevered from the base32. The outer portion 40 is configured to be fixed to the patella at theanterior wall. In particular, the outer intermediate section 40 b andthe outer distal end 40 c can be configured to receive fixation elementsthat extend through the anterior cortical surface and into the patella.Thus, the outer intermediate section 40 b can extend medially from theouter proximal end 40 a, and the outer distal end 40 c can extendmedially from the outer intermediate section 40 b.

Whether the bone plate is in the flat configuration or the curvedconfiguration, the base 32 can be elongate substantially along a firstplane, and the outer portion 40 can extend from the base 32substantially along a second plane, it being understood that each of thebase 32 and the outer portion 40 can be contoured as desired to deviatefrom a plane. The first and second substantial planes can besubstantially orthogonal with respect to to each other.

The fixation holes 26 of the at least one column 42 can be at leastpartially aligned with each other along the longitudinal direction A.For instance, the fixation holes 26 of the at least one column 42 can bepartially aligned with each other along the lateral direction A. In oneexample, the fixation holes 26 of the at least one column 42 can bealigned with each other along the lateral direction A.

In one example, the at least one column 42 of the outer portion 40 caninclude first and second limbs that extend out from the base 32. Thefirst and second limbs can be defined by respective first and secondcolumns 42 a and 42 b of eyelets 28, the columns spaced from each otheralong the longitudinal direction L. In one example, the first column 42a can be spaced from the second column 42 b in the first selectlongitudinal direction. Thus, the second column 42 b can be spaced fromthe first column 42 a in the second select longitudinal direction. Thus,the first column 42 a can be spaced superior with respect to the secondcolumn 42 b when the bone plate 20 is oriented and configured forattachment to the patella.

The first and second columns 42 a and 42 b can be spaced from each otheralong the longitudinal direction L. The eyelets 28 of the first column42 a can be at least partially aligned with respective ones of theeyelets 28 of the second row 34 b along the longitudinal direction L.For instance, the eyelets 28 of the first column 42 a can be partiallyaligned with respective ones of the eyelets 28 of the second column 42 balong the longitudinal direction L. In one example, the eyelets 28 ofthe first column 42 a can be aligned with respective ones of the eyelets28 of the second column 42 b along the longitudinal direction L. Inanother example, the eyelets 28 of the first and second columns 42 a and42 b can be staggered with respect to each other along the lateraldirection A. The first and second columns 42 a and 42 b of eyelets 28can be oriented substantially parallel to each other.

It is appreciated that first and second columns 42 a and 42 b of eyelets28 allow for positional flexibility along both the longitudinaldirection L and the lateral direction A of bone fixation elements thatpass through the eyelets 28 of the base 32 and into the anterior wall ofthe patella, as will be described in more detail below. Thus, the outerportion 40 is configured to be fixed to the anterior wall of the patellaat locations that are offset from each other both along the longitudinaldirection L and the lateral direction A. In this regard, the first andsecond columns 42 a and 42 b can define first and second anteriorextensions of the bone plate 20 when the bone plate 20 is configured andaligned for attachment to the patella 60. Thus, the outer portion 40 ofthe bone plate 20 can be referred to as an anterior portion of the boneplate 20 when the bone plate is aligned and configured for fixation tothe patella.

Selection of one of the first and second columns 42 a and 42 b forfixation allows for positional flexibility along the longitudinaldirection L. Selection of one of the plurality of fixation holes 26 of agiven one of the columns 42 a and 42 b for fixation allows forpositional flexibility along the lateral direction A. Further, one orboth of the columns 42 a and 42 b can be angulated along the anteriorwall so as to provide for additional positional flexibility along thelongitudinal direction L. The application of the base 32 to the lateralhalf of the peripheral rim of the patella along with the fixation of thefirst and second columns 42 a and 42 b to the anterior wall of thepatella permits fixation of the bone plate 20 to the patella in multipleplanes of fixation.

The first column 42 a can define a first lateral end 46 a, a secondlateral end 46 b that is opposite the first lateral end 46 a, and amiddle segment 46 c disposed between the first and second lateral ends46 a and 46 b. The second lateral end 46 b can be said to be spaced fromthe first lateral end 46 a in the first select lateral direction.Similarly, the first lateral end 46 a can be said to be spaced from thesecond lateral end 46 b in the second select longitudinal direction.Thus, the second lateral end 46 b can be spaced from the first lateralend 46 a in at least the medial direction when the bone plate 20 isoriented and configured for fixation to the patella. The first lateralend 46 a can be defined by the outer proximal end 40 a. When the boneplate 20 is placed against the patella, the first lateral end 46 a canextend anteriorly and medially, such that the first middle segment 46 cand the second lateral end 46 b can face the anterior surface of thepatella. The second lateral end 46 b can be defined by the second outerdistal end 40 c. The middle segment 46 c can be defined by the outerintermediate section 40 b.

Similarly, the second column 42 b can define a first lateral end 48 a, asecond lateral end 48 b that is opposite the first lateral end 48 a, anda middle segment 48 c disposed between the first lateral end 48 a andthe second lateral end 48 b. The second lateral end 48 b can be spacedfrom the first lateral end 48 a in the first select lateral direction.The first lateral end 48 a can be spaced from the second lateral end 48b in the second select lateral direction. The first lateral end 48 a canbe defined by the outer proximal end 40 a. When the bone plate 20 isplaced against the patella, the first lateral end 48 a can extendanteriorly and medially, such that the first middle segment 48 c and thesecond lateral end 48 b can face the anterior surface of the patella.The second column 42 b can be spaced from the first column 42 a in theinferior direction. Thus, the first column 42 a can be spaced from thesecond column 42 b in the superior direction. The second lateral end 48b can be defined by the outer distal end 40 c. The middle segment 48 ccan be defined by the outer intermediate section 40 b.

The first column 42 a defines a first lateral length from the firstlateral end 46 a to the second lateral end 46 b. The second column 42 bdefines a second lateral length from the first lateral end 48 a to thesecond lateral end 48 b. The first lateral length can be substantiallyequal to the second lateral length. Thus, the second lateral ends 46 band 48 b can be substantially aligned with each other along thelongitudinal direction L. Alternatively, the first lateral length can begreater than the second length. Thus, the second lateral end 46 b can bedisposed laterally outboard, or medially during use, of the secondlateral end 48 b. Alternatively still, the first lateral length can beless than the second lateral length. Thus, the second lateral ends 48 bcan be disposed laterally outboard, or medially during use, of thesecond lateral end 46 b. As will be appreciated from the descriptionbelow, the first and second columns 42 a and 42 b are each configured toextend anteriorly from the base 32 to the anterior wall of the patella,and medially along the anterior wall of the patella.

The first and second columns 42 a and 42 b can include the same numberof eyelets 28 or a different number of eyelets 28. The eyelets 28 of thefirst column 42 a can be equidistantly spaced from each other along thelateral direction A a respective first distance. Further, the eyelets 28of the second column 42 b can be equidistantly spaced from each otheralong the lateral direction A a respective second distance. Therespective second distance can be equal to the respective firstdistance. Alternatively, the respective second distance can be greaterthan or less than the respective first distance. Further still, therespective first and second distances defined by the eyelets 28 of thefirst and second columns 42 a and 42 b can be the same as or differentthan the first and second distances defined by the eyelets of the firstand second rows 34 a and 34 b, respectively.

The eyelets 28 of the first column 42 a can be offset from the eyelets28 of the second column 42 b a distance along the longitudinal directionL that can be greater than one or both of the respective first andsecond distances. Accordingly, the outer portion 40 can include at leastone cross-beam 50 that extends between the first and second columns 42 aand 42 b, and is connected to each of the first and second columns 42 aand 42 b. The cross-beam 50 can be monolithic with one or both of thefirst and second columns 42 a and 42 b. Alternatively or additionally,the cross-beam 50 can be can be secured to one or both of the first andsecond columns 42 a and 42 b using any attachment technique as desired.The cross-beam 50 can include at least one eyelet 28, and first andsecond links 30 that are joined to the first and second columns 42 a and42 b, respectively. In particular, one or both of the links 30 can bejoined to respective eyelets 28 of the first and second columns 42 a and42 b, respectively. The at least one eyelet 28 of the cross-beam 50 canbe spaced from the eyelets 28 of the first and second columns 42 a and42 b any distance along the longitudinal direction L as desired. Inparticular, the at least one eyelet 28 of the cross-beam 50 can bespaced from the eyelets 28 of the first and second columns 42 a and 42 ba distance along the longitudinal direction L can be the equal to ordifferent than the respective first and second distances that theeyelets 28 of the first and second columns 42 a and 42 b are spaced fromeach other along the lateral direction A.

The outer distal end 40 c of the outer portion 40 can be defined by theeyelets 28 of the outer portion 40 that are disposed outboard from thecross-beam in the first select lateral direction. Thus, the secondlateral end 46 b of the first column 42 a can be defined by the at leastone eyelet or eyelets 28 that are spaced from the cross-beam 50 in thefirst select lateral direction. The second lateral end 46 b of the firstcolumn 42 a can be defined by the at least one eyelet or eyelets 28 thatare spaced from the cross-beam 50 in the first select lateral direction.The second lateral end 46 b and 48 b can include a single eyelet 28.Alternatively, the second lateral end 46 b and 48 b can include aplurality of eyelets 28 as desired.

The first and second outer sections 32 b and 32 c of the base 32, andthus the first and second longitudinal ends 37 a and 37 b of the firstrow 34 a can be defined by those eyelets 28 of the first and second rows34 a and 34 b that are disposed longitudinally outboard with respect tothe eyelets 28 of the outer portion 40. For instance, the at least oneeyelet 28 or eyelets 28 of the first longitudinal end 37 a can be spacedfrom the outer portion 40 in the first select longitudinal direction.Thus, in one example, the at least one eyelet 28 or eyelets 28 of thefirst longitudinal end 37 a can be spaced from the first column 42 a inthe first select longitudinal direction L. Similarly, the at least oneeyelet 28 or eyelets 28 of the second longitudinal end 37 b can bespaced from the outer portion 40 in the second select longitudinaldirection. Thus, in one example, the at least one eyelet 28 or eyelets28 of the second longitudinal end 37 b can be spaced from the secondcolumn 42 b in the second select longitudinal direction L.

Likewise, the first longitudinal end 38 a of the second row 34 b can bedefined by those eyelets 28 of the second row 34 b that are disposedlongitudinally outboard with respect to the eyelets 28 of the outerportion 40 in the first select longitudinal direction. Thus, in oneexample, the at least one eyelet 28 or eyelets 28 of the firstlongitudinal end 38 a can be spaced from the first column 42 a in thefirst select longitudinal direction L. Similarly, if the second row 34 bincludes a second longitudinal lend 38 b, the at least one eyelet 28 oreyelets 28 of the second longitudinal end 38 b can be spaced from theouter portion 40 in the second select longitudinal direction. Thus, inone example, the at least one eyelet 28 or eyelets 28 of the secondlongitudinal end 38 b can be spaced from the second column 42 b in thesecond select longitudinal direction L.

It should be appreciated that while the outer portion 40 has beendescribed in accordance with one embodiment, and that numerousalternative designs are envisioned suitable for implantation asdescribed in more detail below. For instance, while the outer portion 40has been described as including first and second rows columns 42 a and42 b, the outer portion 40 can include any number of columns as desired,greater than or equal to one. The first column 42 a can define an outerboundary of the outer portion 40 with respect to the first selectlongitudinal direction. The second column 42 a can define an outerboundary of the outer portion 40 with respect to the second selectlongitudinal direction. Additional columns can be disposed between thefirst and second columns 42 a and 42 b with respect to the longitudinaldirection.

Referring now to FIGS. 1A-1C and 2A-2C, the bone plate 20 can beprovided in many different sizes as desired. In one non-limitingexample, bone plates 20 having different longitudinal lengths areenvisioned. As illustrated in FIGS. 1A-1C, the cross-beam 50 includesfirst and second eyelets 28 that are disposed between the first andsecond columns 42 a and 42 b. Further, the middle segment 37 c of thefirst row 34 a includes four eyelets 28. The middle segment 37 c of thesecond row 34 b also includes four eyelets. It is recognized, however,that the various segments of the bone plate 20 can include any number ofeyelets 28 as desired. As illustrated in FIGS. 2A-2C, the cross-beam 50includes a single eyelet 28 that is disposed between the first andsecond columns 42 a and 42 b. Further, the middle segment 37 c of thefirst row 34 a includes three eyelets 28. The middle segment 37 c of thesecond row 34 b also includes four three. It is recognized, however,that the various segments of the bone plate 20 can include any number ofeyelets 28 as desired. It should be appreciated, however, that theintermediate section 32 a of the base of a first bone plate 20 asillustrated in FIGS. 1A-1C can include a greater number eyelets 28 thatextend along the longitudinal direction L compared to the eyelets 28 ofthe intermediate section 32 a of a second bone plate 20 illustrated inFIGS. 2A-2C. Further, the cross-beam 50 of the first bone plate asillustrated in FIGS. 1A-1C can include a greater number of eyelets 28that extend along the longitudinal direction L compared to the eyeletsof the cross-beam 50 of the second bone plate of FIGS. 2A-2C.

Thus, it should be appreciated that the surgical provider can beprovided with a kit of bone plates 20 of different sizes. The differentsizes can be defined by the eyelets 28 as described above with respectto the bone plate 20 illustrated in FIGS. 1A-1C, and the bone plate 20illustrated in FIGS. 2A-2C. It is recognized that the different sizesmay be achieved in any suitable alternative manner as desired. Furtherstill, the kit can include bone plates of different shapes suitable forimplantation using the method described below. For instance, the base 32can include a single row, or can include more than two rows. Further,the outer portion 40 can include one cross-beam or a plurality ofcross-beams. Further still, the outer portion 40 can include more thantwo columns. The surgical provider can select the bone plate 20 deemedto be most suitable for the patella to which the bone plate 20 is to beaffixed. The selection can be based at least in part on one or both ofthe size of the patella, and the shape of the patella.

Further, bone plates 20 can be provided to the surgical care provider asdescried above with respect to either or both of FIGS. 1A-1C and FIGS.2A-2C. Thus, the bone plate 20 can be pre-formed in the manner describedabove, so as to be contoured to the shape of a patella prior to beingsent to the surgical provider. It is appreciated that the pre-sized andpre-shaped implant can be further cut and shaped by the surgical careprovider to define contour that further fits the patella to which thebone plate 20 is to be affixed. It is envisioned that a pre-sized andpre-shaped implant is contoured so as to substantially fit the patient'spatella prior to any cutting or manipulation by the surgical provider.

In an alternative embodiment, the surgical provider can be provided witha flat mesh sheet having an array of eyelets 28 that are spaced fromeach other along the row direction and the column direction, andconnected to each other by the links 30 as described above. The meshsheet can be cut to a shape described herein so as to define the boneplate 20, and contoured to the fractured patella to which the bone plateis to be fixed.

A method of fixation of the bone plate 20 to the patella to repairpatella fractures will now be described. As will become appreciated fromthe description below, the bone plate 20 can provide a multiplanarfixation with the bone plate 20 that can provide a low profile fixationconstruct against the patella. The method of fixation can maintainanatomic reduction under direct visualization of complex articularinjuries and of the articular reduction with compression plating andinterfragmentary screw fixation, including inferior pole comminution,while minimizing or at least reducing disruption to the vascular supplyto the patella compared to conventional plating techniques.

Referring now to FIG. 3A, the patella 60 is an ovoid, triangular shapebone. The proximal roughly 75 percent of the patella 60 is composed ofcortical-cancellous bone anteriorly with thick articular cartilage onthe posterior surface. Distally near the inferior pole 76, the patella60 is composed of thinner cancellous bone. The patella 60 defines anarticular surface 66 (see FIG. 3B) that is mainly divided by the majorvertical ridge into the lateral and medial facets, with the lateralfacet typically being the larger of the two. The patella 60 lies in asubcutaneous position with strong fascial attachments that compose thequadriceps tendon 68 proximally (quadriceps tendon 68 shown only in FIG.3A for the purpose of simplicity), the retinaculum medially andlaterally, and the patellar tendon 72 distally. These soft tissuestructures together with the patella 60 comprise the extensor mechanism.The quadriceps tendon 68 originates from the superior pole 74 and isformed from a blending of the insertions of the four quadriceps muscles:rectus femoris, vastus medialis, vastus lateralis, vastus intermedius.The patellar tendon originates from the inferior pole 76 and inserts onthe tibia tubercle. The patella retinaculum is formed from portions ofthe deep investing fascia lata with the vastus medialis and vastuslateralis aponeurotic fibers. It travels along the medial and lateralaspect of the patella 60 to insert on the proximal tibia and functionsto assist with knee extension.

Historically, the intraosseous blood supply to the patella 60 wasthought to originate from two main arterial systems that are themidpatellar vessels and the polar vessels. The midpatellar vesselspenetrate the middle third of the patella, and the polar vesselspenetrate the patella apex. However, more recent studies havedemonstrated that the largest intraosseous arterial supply to thepatella 60 in fact enters at the inferior or distal pole 76 andpredominantly enters inferomedially. In addition, a deep peripatellaranastomotic ring has also been found that provides arterial bloodsupply. Because conventional understandings of the locations of primaryblood supply to the patella 60 were inaccurate, conventional bone platesbased on these conventional understandings risked a resulting avascularnecrosis. The present method of fixation can avoid disruption of boththe predominate inferomedial vessel and the peripatellar ring in orderto preserve perfusion following the patella fracture fixation.

Two main surgical approaches for patella fractures include a midlinelongitudinal approach and a lateral parapatellar approach. The midlinelongitudinal approach includes creating a midline vertical incision downto the level of the retinaculum. Medial and lateral tissue flaps areraised to expose the extent of the retinacular tears. The presentinventors have recognized the midline longitudinal approach createsdifficulty visualizing the articular surface. Accordingly, the method offixation includes a lateral parapatellar approach. The lateralparapatellar approach is believed to limit disruption to the patellavascularity, which as described above has been found to be primarilyinferomedial. Thus, the method of fixation can include the step ofcreating a longitudinal skin incision 75 along the lateral border of thepatella. The step of creating the incision 75 can further includecreating the incision over the lateral edge of the patella down to theavascular subfascial layer. In one example, and the incision 75 can bemade from the tibial tubercle to a location superior of the superiorpole of the patella. For instance, the incision 75 can be made to alocation between one and three inches above the superior pole of thepatella. A limited lateral tissue flap can be raised to gain access tothe articular capsule of the knee. It is appreciated that the incisionalong the lateral border of the patella can minimize the size of thelateral soft tissue flap for the lateral parapatellar arthrotomy. Priorto creating the incision, the knee is typically placed intoapproximately 20-30 degrees of flexion.

Once the incision has been created, the method of fixation can includethe step of performing a lateral parapatellar arthrotomy. The lateralparapatellar arthrotomy can originate from the tear in the lateralretinaculum that is commonly present in patella fractures. Thearthrotomy allows for direct visualization of the articular surface 66,which significantly reduces the difficulty of obtaining an anatomicreduction compared to conventional techniques. In particular, as isdescribed in more detail below, the access to the patella 60 through thelateral parapatellar arthrotomy can allow for angular manipulation ofthe patella to expose the articular surface and ensure continuity of thearticular surface 66 after fracture reduction. Thus, the arthrotomy canallow for exposure and reduction of the articular fragments. Thus, themethod can further include the step of directly visualizing thearticular surface of the patella. The method can further include thestep of exposing and reducing the articular fragments while directlyvisualizing the articular surface. Further, the direct visualization ofthe articular surface allows for visualization of the placement of thebone plate 20 on the patella 60 at locations that avoids interferencewith the articular surface. Thus, the method can further include thestep of directly visualizing the articular surface while fixing the boneplate 20 to the patella 60. The method can further include the step offixing the bone plate 20 to the patella 60 while avoiding theinferomedial vascularity to the patella. In particular, the bone plate20 can be placed against the bone plate 20 without causing the pate 20to lie against the inferomedial vascularity to the patella. Once thelateral parapatellar arthrotomy has been completed, the method caninclude the step of irrigating the fracture site of the patella. Themethod can also include the step of removing the fracture hematoma. Themethod can further include the step of visually inspecting the patella60 for loose bodies.

Referring now to FIG. 3B, the method of fixation can include the step ofreducing the at least one fracture or fractures of the patella 60. Inparticular, the reducing step can be performed after the arthrotomy hasbeen completed. The patella 60 can be everted so as to expose thearticular surface 66, such that the method can include the step ofdirectly visualizing the articular surface 66. For instance, the patellacan be angulated between 75 degrees and 180 degrees substantially abouta superior-inferior axis to gain visual access to the articular surface66, and in particular to gain access to the at least one fracturelocation or fracture locations of the articular surface 66. The angularmanipulation of the patella can also allow for easy removal of hematomasat fracture locations of the articular surface 66. In one example,during bone plate fixation, the patella can be angulated less than 180degrees so as to simultaneously allow for access to the lateral aspectof the peripheral rim 78 of the patella 60. Thus, the bone plate 20 canbe fixed to a lateral aspect of the rim 78 while visualizing thearticular surface to ensure integrity and continuity of the articularsurface. At certain times during the surgical procedure, the patella 60can be angulated more or less as desired so as to gain the desiredvisual access to the articular surface while allowing for fixation ofthe bone plate 20 to the patella 60.

In one example, the step of reducing the patella can include the step ofdriving Kirschner wires (K-wires) 79 into select ones of the patellabone fragments 80, and manipulating the K-wires to adjust the positionof the bone fragment or fragments 80. The K-wires can have any suitablediameter as desired. In one example, the K-wires can have a diameterbetween and including 1.5 mm and 2 mm. Thus, the K-wires can be used asjoysticks that can translate and angulate the bone fragments to therebyreduce the at least one fracture or fractures. Reduction can further beperformed using interfragmentary small fragment compression screws thatcan adjoin small fragments of the patellar fracture to each other, andreduce the fragments. During reduction, the patella 60 can be angulatedas described above so as to provide visual access to the articularsurface. The angulation can provide both direct visualization offracture fragments and direct visualization of the articular surface. Iffurther exposure or inversion is desired, the arthrotomy can be extendedsuperiorly with a cuff of quadriceps tendon left on the vastus lateralleft for later repair. Thus, the method can include the step ofangulating the patella, and directly visualizing both at least a portionup to all of the fracture fragments and the articular surface.Alternatively, the patella 60 can be angulated intermittently aftercompletion of a reduction operation to inspect the articular surface, totherefore assess whether additional reduction is to be performed. Thereduction can be performed until the articular surface is aligned andthe extensor mechanism is restored.

Referring now to FIG. 3C, fracture can further be performed by capturingbone fragments 80 to be reduced between the arms 82 of reduction clamps84, and bringing the arms together so as to thereby urge the capturedbone fragments 80 toward each other. The reduction clamps 84 can be usedalone or in combination with either or both of the K-wires 79 andinterfragmentary small fragment compression screws. Similarly, theK-wires 79 can be used alone or in combination with either or both ofthe reduction clamps 84 and the interfragmentary small fragmentcompression screws.

In one example, the K-wires 79 alone or in combination with theinterfragmentary small fragment compression screws can be used to reducethe at least one fracture or fractures, and the reduction clamps canhold the fracture fragments in their reduced state while the bone plate20 is fixed to the patella 60. In one example, smaller fragments areheld together with the threaded K-wires 79 alone or in combination withthe interfragmentary small fragment compression screws so as toconstruct larger fragments that can then be reduced to one another underpressure provided by the reduction clamps. The bone plate 20 can then beapplied to the patella 60. In this regard, it should be appreciated thatthe K-wires 79 should be driven into the respective bone fragments atlocations that do not interfere with placement of the bone plate 20 ontothe patella 60. Depending on the nature of the fracture, the reducingstep can reduce fractures at the articular surface so as to achieverealignment and continuity of the articular surface.

Referring now to FIGS. 4A-4H generally, once the fractured patella 60has been reduced, the bone plate 20 can be fixed to the patella 60. InFIGS. 4A-4H, the K-wires 79 and reduction clamps 84 are not shown inorder to more clearly illustrate the bone plate 20, but it isappreciated that the K-wires 79 and reduction clamps 84 can remain inplace until fixation of the bone plate 20 to the patella 60 hasstabilized the reduced fragments, at which point the K-wires 79 andreduction clamps 84 can be removed.

After the patella 60 has been reduced, the method can include the stepof inserting the bone plate 20 through the lateral parapatellar incision75, and positioning the bone plate around at least a portion of thepatella 60. For instance, the plate 20 can be positioned such that theinner surface 24 a faces the patella 60. A first portion of the plate20, which can be defined by the base 32, can face a lateral side of theperipheral rim 78. A second portion of the plate 20, which can bedefined by the outer portion 40, can face the anterior surface 86 of thepatella 60. A first end of the first portion, which can be defined bythe first outer section 32 b of the base 32, can face the superior pole74 of the patella. A second end of the first portion, which can bedefined by the second outer section 32 c of the base 32, can face theinferior pole 76 of the patella 60. The plate 20 can be configured to bein alignment with the patella 60 beneath the patellar tendon andquadriceps tendon while also extending over the anterior wall of thepatella 60. Thus, the plate 20 can span half or more of the perimeter ofthe patella. For instance, the bone plate can span a lateral half of theperimeter. As described above, the plate size can be selected based onpatient size and the shape of the patella.

In particular, the plate 20 can be contoured to fit around theperipheral rim 78 of the reduced patella and the cortical anteriorsurface 86 of the patella 60. For instance, the bone plate 20 can bepositioned such that the intermediate section 32 a of the base 32 facesthe lateral end of the peripheral rim 78 of the patella 60, and theouter portion 40 faces the anterior surface 86 of the patella 60. Thefirst outer section 32 b of the base 32 can define a first extensionthat faces the patella 60 at a location superior of the intermediatesection 32 a. For instance, the first outer section 32 b of the base 32can define a first extension that faces a bony surface of the superiorpatella at a location posterior of (beneath) the quadriceps tendon. Thesecond outer section 32 c of the base 32 can define a second extensionthat is configured to face the patella 60 at a location inferior of theintermediate section 32 a. For instance, the second outer section 32 cof the base 32 can define a second extension that faces thenon-articulating distal pole of the patella 60 at a location posteriorof (beneath) the patellar tendon. The plate 20 is fashioned to achievefixation to the patella 60 at each major fracture fragment withoutencroachment on the quadriceps and patellar tendinous insertions on thesuperior and inferior pole of the patella 60. This avoids releasing thequadriceps and patellar, which can already be compromised by the injurythat caused the patella fracture, from the patella 60. It is recognizedthat the shape and contour of the plate 20 can be modified to adapt tovarious different fracture patterns.

As described above a fixation system can include the bone plate 20 and aplurality of fixation elements 88. The fixation element 88 can include ahead 90 and a shaft 92 that extends out with respect to the head 90. Atleast a portion of the shaft 92 can be threaded. For instance, anentirety of the shaft can be threaded. In another example, the fixationelement can be configured as a lag screw wherein the distal end of theshaft 92 is threaded, but the shaft remains unthreaded between the headand the threaded distal end. The shaft 92 can have a length sufficientso as to extend through a cortical wall of the rim 78 at a firstlocation, extend through the patella, and be embedded in a cortical wallof the rim at a second location. The second location can besubstantially opposite the first location. Thus, in one example, theshaft 92 can have a length sufficient so as to extend through thelateral side of the rim 78, extend through the patella 60, and embed inthe cortical wall at the medial side of the rim 78. In another example,the shaft 92 can have a length sufficient so as to extend through theproximal pole of the rim 78, through the patella 60, and embed in thecortical wall at the superior pole of the rim 78. In this regard, thefixation element 88 can be referred to as a bicortical screw.Alternatively, the shaft 92 can be configured as a unicortical screwwhose shaft has a length suitable to threadedly purchase with thecortical wall at the location of the bone through which the fixationelement 88 extends. The fixation elements 88 can include shafts 92having different diameters. For instance, while certain ones of theshafts can have a diameter of 2.4 mm and certain others of the shaftscan have a diameter of 2.7 mm are envisioned, shafts of any suitablealternative diameter are contemplated by the present disclosure.

Further, one or more of the fixation elements 88 can be configured ascompression screws. In particular, at least one or both of the externalsurface of the head 90 and the internal surface of the eyelet 28 thatdefines the fixation hole 26 can be unthreaded. Accordingly, as the head90 is brought into the fixation hole 26 while the shaft is driven intothe patella 60, the head 90 is configured to compress the bone plate 20against the patella 60 as the shaft 92 is driven into bone. In otherexamples described below (see FIG. 4G), one or more of the fixationelements 88 can be configured as a locking screw, whereby the externalsurface of the head 90 is threaded. Further, the internal surface of theeyelet 28 that defines the fixation hole 26 can also be threaded. Thus,as the head 90 is brought into the fixation hole 26 while the shaft isdriven into the patella 60, the head 90 is configured to threadedly matewith the bone plate 20 in the fixation hole 26. While certain steps offixing the bone plate 20 to the patella 60 are described in connectionwith certain types of fixation elements, it should be appreciated thatthe disclosure is not limited to the particular type of fixation elementdescribed, and that any suitable alternative type of fixation elementcould instead be used as desired. Further, the number of fixationelements inserted through the bone plate 20 and into the patella 60, andsize of screws can often be determined by fracture pattern and bonequality of the patella 60.

Referring now to FIGS. 1A-2C and 4A-4B, after the plate 20 has beenpositioned around the patella 60, at least one first or lateral fixationelement 94 of the plurality of fixation elements 88 can be driventhrough one of the fixation holes 26 of the eyelets 28 in alateral-to-medial direction. The at least one lateral fixation element94 can thus be configured to achieve initial fixation of the plate 20 tothe patella 60. Fixation of the bone plate 20 to the patella with the atleast one lateral fixation element 94 can achieve stable compression andabsolute stability of the major fracture fragments.

The at least one lateral fixation element 94 can be configured as abicortical compression screw, though as described above any one or moreup to all of the at least one lateral fixation element 94 can beconfigured as any suitable type of alternative fixation element asdescribed above. In one example, the lateral fixation element 94 can bedriven through one of the fixation holes 26 of the intermediate section32 a and at least into the lateral aspect of the rim 78. The threadedshaft 92 can threadedly purchase with cortical bone at the anterioraspect of the rim 78. Further, the lateral fixation element 94 can bedriven into the reduced patella 60 until the threaded shaft 92 extendsacross the patella 60 and can threadedly purchase in cortical bone onthe medial side of the patella 60.

The at least one lateral fixation element 94 can include a plurality oflateral fixation elements 94 that can be driven into respective fixationholes 26 of the intermediate section 32 a. While a pair of lateralfixation elements 94 are shown, any suitable number of fixation elements88 can be driven through the respective fixation holes 26 of theintermediate section 32 a into the patella 60, with care taken so thatthe fixation elements 88 inserted through the intermediate section 32 ado not interfere with insertion of other fixation elements 88 to beinserted through other locations of the bone plate 20 and into thepatella. The lateral fixation elements 94 can be inserted into differentones of the first and second rows 34 a and 34 b, or can be inserted intothe same row as desired. For instance, the at least one lateral fixationelement 94 can be driven through a bone fixation hole 26 defined by themiddle segment 37 c of the first row 34 a. Alternatively oradditionally, the at least one lateral fixation element 94 can be driventhrough a bone fixation hole 26 defined by the middle segment 38 b ofthe second row 34 b. The lateral fixation elements 94 can, for instance,be driven in the medial direction into the superior and inferior polesof the patella 60 to seat the plate 20 against the patella 60. It shouldalso be appreciated that the bicortical fixation of the plate 20 to thepatella 60 in the lateral-to-medial direction can be multiplanar.

Referring now to FIGS. 4C-4H generally, after initial fixation of theplate 20 to the patella 60, the contour of the plate 20 with respect tothe patella 60 can be inspected, and additional contouring of at leastone or more up to all of the first and second outer sections 32 b and 32c of the base, and the first and second columns 42 a and 42 b can beperformed. Advantageously, the plate 20 can achieve the fixationdescribed herein without overlapping the articular surface of thepatella. The contouring of the first and second columns 42 a and 42 bcan also achieve a low profile of the plate 20 on the anterior surface86 of the patella 60.

Referring to FIGS. 1A-2C and 4C-4D, at least one second or superiorfixation element 96 can be driven through the plate 20 and into thepatella 60 in the distal (or superior-to-inferior) direction so as tothereby fix a superior end of the plate 20 to the patella 60. Inparticular, the at least one superior fixation element 96 can be driventhrough a respective at least one of the bone fixation holes 26 of thefirst outer section 32 b of the base 32 and into a bony surface of thepatella 60 at the superior or proximal end of the patella 60. Forexample, the at least one superior fixation element 96 can be driventhrough the peripheral rim 78 of the patella 60 at the superior pole ofthe patella 60. Because the first outer section 32 b of the base 32 isdisposed posterior of the quadriceps tendon, the at least one superiorfixation element 96 can likewise be driven through the plate 20 and intothe patella 60 at a location posterior of the quadriceps tendon. Thus,it can be said that the at least one superior fixation element 96 can bedriven through an extension of the bone plate 20 that is disposedagainst a bony surface of the superior patella at a location posteriorof the quadriceps tendon. The at least one fixation hole 26 thatreceives the at least one superior fixation element 96 can be aninferior-most hole 26 of the bone plate 20, though it should beappreciated that any fixation hole 26 of the plate 20 aligned with thesuperior end of the patella 60 can be used.

In one example the at least one superior bone fixation element 96 can bedriven through a bone fixation hole 26 defined by the first longitudinalend 37 a of the first row 34 a. Alternatively or additionally, the atleast one superior bone fixation element 96 can be driven through a bonefixation hole 26 defined by the first longitudinal end 38 a of thesecond row 34 b.

The at least one superior fixation element 96 can be configured as abicortical compression screw, though as described above one or more upto all of the at least one superior fixation element 96 can beconfigured as any suitable alternative type of fixation elementdescribed above. For instance, the at least one superior fixationelement 96 can be configured as a unicortical compression screw. In oneexample, the at least one superior fixation element 96 can be driventhrough one of the fixation holes 26 of the first outer section 32 b andat least into the superior aspect of the rim 78. The threaded shaft 92can threadedly purchase with cortical bone at the superior end of thepatella. Further, the at least one superior fixation element 96 can bedriven into the reduced patella 60 until the threaded shaft 92 extendsacross the patella 60 and can threadedly purchase in cortical bone atthe inferior end of the patella 60.

Alternatively, if the at least one superior fixation element 96 is aunicortical screw, the shaft 92 threadedly purchases with the corticalwall at the superior end of the patella 60, but does not extend acrossthe patella 60 a sufficient distance so as to threadedly purchase withthe cortical wall at the inferior end of the patella 60. It isrecognized that the superior end of the patella 60 has dense bone thatcan be suitable for reliable threaded purchase by the at least onesuperior fixation element 96, and thus the superior fixation element 96can be a unicortical fixation element.

Because the at least one superior fixation element 96 can be acompression screw, the head 90 of the at least one superior fixationelement 96 can compress the plate 20 against the superior end of thepatella 60 at a location posterior of the quadriceps tendon. Any numberof superior fixation elements 96 can be driven through respectivefixation holes 26 of the plate 20 and into the patella 60 so as toprovide fixation of the plate 20 to the patella as desired. Forinstance, the fixation of the plate 20 to the superior end of thepatella 60 can occur along more than one plane, thereby enhancingfixation.

Referring now to FIGS. 1A-2C and 4E-4F, at least one third or inferiorfixation element 98 can be driven through the plate 20 and into thepatella 60 in the proximal (or inferior-to-superior) direction so as tothereby fix an inferior end of the plate 20 to the patella 60. Inparticular, the at least one inferior fixation element 98 can be driventhrough a respective at least one of the bone fixation holes 26 of thesecond outer section 32 c of the base 32 and into a bony surface of thepatella 60 at the inferior or distal end of the patella 60. For example,the at least one inferior fixation element 98 can be driven through theperipheral rim 78 of the patella 60 at the inferior pole of the patella60. In particular, the at least one inferior fixation element 98 can bedriven into the non-articulating inferior pole of the patella 60.Because the second outer section 32 c of the base 32 is disposedposterior of the patellar tendon, the at least one inferior fixationelement 98 can likewise be driven through the plate 20 and into thepatella 60 at a location posterior of the patellar tendon. Thus, it canbe said that the at least one inferior fixation element 98 can be driventhrough an extension of the bone plate 20 that is disposed against abony surface of the inferior end of the patella 60 at a locationposterior of the patellar tendon. The at least one fixation hole 26 thatreceives the at least one inferior fixation element 98 can be aninferior-most hole 26 of the bone plate 20, though it should beappreciated that any fixation hole 26 of the plate 20 aligned with theinferior end of the patella 60 can be used

In one example the at least one inferior bone fixation element 98 can bedriven through a bone fixation hole 26 defined by the secondlongitudinal end 37 b of the first row 34 a. Alternatively oradditionally, the at least one superior bone fixation element 98 can bedriven through a bone fixation hole 26 defined by a second longitudinalend of the second row 34 b in examples where the second row 34 bincludes a second longitudinal end.

It should be appreciated that the at least one second or superiorfixation element 96 can be driven antegrade through the plate 20 in thedistal direction, and the at least one third or inferior fixationelement 98 can be driven retrograde through the plate 20 in the proximaldirection, thereby provide interfragmentary compression across thefracture fragments of the patella 60 and correspondingly achievingstability of the fracture.

The present disclosure recognizes that the inferior pole of the patella60 can be more osteoporotic than the superior pole of the patella 60.Further, the fracture of the patella at the inferior pole can be morecomminuted than at the superior pole. Accordingly, the at least oneinferior fixation element 98 can be configured as a locking screw.Further, the at least one inferior fixation element 98 can be configuredas a bicortical screw. It should be appreciated, however, as describedabove that one or more up to all of the at least one inferior fixationelement 98 can be configured as any suitable alternative type offixation element described above. In one example, the at least oneinferior fixation element 98 can be driven through one of the fixationholes 26 of the second outer section 32 b and at least into the inferiorpole of the patella 60. The threaded shaft 92 can threadedly purchasewith cortical bone at the inferior pole. Further, the at least oneinferior fixation element 98 can be driven into the reduced patella 60until the threaded shaft 92 extends across the patella 60 and canthreadedly purchase in cortical bone at the superior end of the patella60. As described above, the cortical bone at the superior end of thepatella 60 is often more dense and strong than the cortical bone at theinferior end of the patella 60. Accordingly, because the at least oneinferior fixation element 98 can be bicortical, the at least oneinferior fixation element 98 can reliably threadedly purchase withstrong dense bone.

Because the at least one inferior fixation element 98 can be a lockingscrew, the head 90 of the at least one inferior fixation element 98 canthreadedly mate with the plate 20 inside the fixation hole 26. Thus, thefixation holes 26 at the second outer section 32 c of the base 32 can beconfigured as internally threaded locking holes. Because the at leastone inferior fixation element 98 can be configured as a locking screw,the head 90 does not compress the plate against the patella 60 when theat least one inferior fixation element 98 is fully seated in the boneplate 20 and bicortically secured to the patella 60. Any number ofinferior fixation elements 98 can be driven through respective fixationholes 26 of the plate 20 and into the patella 60 so as to providefixation of the plate 20 to the patella 60 as desired. For instance, thefixation of the plate 20 to the inferior end of the patella 60 can occuralong more than one plane, thereby enhancing fixation.

Referring now to FIGS. 1A-2C and 4G-4H, at least one fourth or anteriorfixation element 100 can be driven posteriorly through an anteriorportion of the plate 20 into the anterior wall of the patella 60 that isopposite the articular surface 66. The anterior wall defines theanterior surface 86. As described above, the anterior portion of theplate 20 can be defined by the outer portion 40. Thus, the at least oneanterior fixation element 100 can be driven through a respective atleast one fixation hole of the outer portion 40 of the bone plate 20 soas to fix the plate 20 to the anterior surface 86 of the patella 60. Inparticular, the at least one anterior fixation element 100 can be driventhrough a respective at least one hole of the first column 42 a, thesecond column 42 b, or each of the first and second columns 42 a and 42b. As described above, the anterior, superior, and inferior fixationelements can achieve multiplanar fixation of the bone plate 20 to thepatella 60. Fixation of the anterior portion of the plate 20 to thepatella 60 provides an additional plane of fixation so as to furtherstabilize comminuted patella fractures, and to allow for fixation in theanteroposterior direction.

The at least one anterior fixation element 100 can be configured as alocking screw or a compression screw. Accordingly, the anterior fixationelement 100 is driven posteriorly through the fixation holes 26 of theanterior portion of the plate 20 until fully seated in the plate 20. Ifthe anterior fixation element 100 is a compression screw, then the head90 of the anterior fixation element 100 can compress the plate 20against the anterior surface 86 of the patella 60. Alternatively, if theanterior fixation element 100 is a locking screw, then the head 90 ofthe anterior fixation element 100 can threadedly purchase with athreaded locking hole 26 of the plate 20 at the anterior portion of theplate 20.

Further, the at least one anterior fixation element 100 can beconfigured as a unicortical screw. Accordingly, when the at least oneanterior fixation element 100 is fully seated in the respective at leastone fixation hole 26, the shaft 92 terminates anterior of the corticalbone at the anterior wall of the patella 60. As a result, the shaft 92can be configured so as to not interfere with the continuity of thearticular surface 66. Direct visualization of the articular surfaceachieved by the angulation of the patella 60, as well as anteroposteriorand lateral fluoroscopy, can be used to ensure that at least oneanterior fixation element 100 has not violated the articular surface 66.It is recognized that the at least one anterior fixation element 100 caninclude a single anterior fixation element 100 that is fixed to theplate 20 and the patella 60 through a respective fixation hole 26, or aplurality of anterior fixation elements 100 fixed to the plate 20 andthe patella 60 through a respective plurality of fixation holes 26. Forinstance a first one of the plurality of anterior fixation elements 100can be driven through the first column 42 a, and a second one of theplurality of anterior fixation elements 100 can be driven through thesecond column 42 b. In one example, a first one of the plurality ofanterior fixation elements 100 can be driven through the second lateralend 46 b of the first column 42 a. A second one of the plurality ofanterior fixation elements 100 can be driven through the second lateralend 48 b of the second column 42 b.

While the at least one superior fixation element 96 is described asbeing driven through the plate 20 and into the patella 60 prior todriving the at least one inferior fixation element 98 through the plate20 and into the patella 60, and the at least one inferior fixationelement 98 is described as being driven through the plate 20 and intothe patella 60 prior to driving the at least one anterior fixationelement 100 through the plate 20 and into the patella 60, fixation ofthe plate 20 to the patella 60 can occur in any order as desired. Forinstance, the at least one inferior fixation element 98 can be driventhrough the plate 20 and into the patella 60 prior to driving the atleast one superior fixation element 96 through the plate 20 and into thepatella 60. It should be appreciated that the steps of fixing the plate20 to the patella 60 allows fixation of each fragment of the patella 60,for instance in situations where large pieces of articular comminutionexist.

Referring now to FIGS. 1A-2C and 5, it is recognized that the inferiorpole 76 of the patella 60 can often be comminuted, and can containosteoporotic bone. In fact, inferior pole comminution has been observedin 88% of fractures of the patella 60. Accordingly, fixation of the boneplate 20 to the patella 60 can be augmented by suture fixation. Themethod of fixation can further include the step of augmenting fixationof the plate 20 to the patella 60 by fixing at least one suture to thepatellar tendon 72 and to the plate 20. In one example, the sutures canbe configured as FiberWire® sutures commercially available from Arthrex,having a place of business in Naples, Fla., though it should beappreciated that any suitable suture is envisioned. Thus, the method caninclude the step of attaching one or more sutures 102 to the patellartendon 72. The sutures 102 can thus be included in the fixation system.In one example, the sutures 102 can be passed beneath the anteriorportion of the plate 20, between the plate 20 and the patella 60, andmedially and laterally through the patellar tendon 72 in a Krackowconfiguration. The free end of the suture 102 can then be passed overthe plate in the inferior direction, and tied to the plate 20. Forinstance, the sutures 102 can be tied to at least one of the links 30 ofthe bone plate 20. In one example, the sutures 102 can be passed throughthe fixation holes 26 of the anterior portion of the plate 20 andsubsequently tied to the plate 20. The fixation holes 26 can be definedby the second column 42 b. Thus, the suture 102 can further anchor thebone plate 20 to the patellar tendon 72, which enhances the stability ofthe bone plate 20 at the inferior pole 76. It is thus appreciated thatthe suture 102 can augmenting

It is desirable for the knee to be in extension during the suturefixation. The retinacular tears can be repaired with any suitable suturein a figure-eight pattern. The suture used for repairing retinaculartears can, for example, be a #2 Ethibond® suture commercially availablefrom Ethicon, having a place of business in Somerville, N.Y., or #2Fiberwire® sutures.

It should be noted that the illustrations and discussions of theembodiments shown in the figures are for exemplary purposes only, andshould not be construed limiting the disclosure. One skilled in the artwill appreciate that the present disclosure contemplates variousembodiments. Additionally, it should be understood that the conceptsdescribed above with the above-described embodiments may be employedalone or in combination with any of the other embodiments describedabove. It should further be appreciated that the various alternativeembodiments described above with respect to one illustrated embodimentcan apply to all embodiments as described herein, unless otherwiseindicated.

1. A method of fixing a fractured patella, the method comprising thesteps of: creating a longitudinal skin incision along a lateral borderof the patella; inserting a bone plate through the incision and aroundat least a portion of the patella, such that the bone plate faces alateral portion of a circumferential rim of the patella, and at leastone of an inferior pole of the patella and a superior pole of thepatella; driving at least one lateral fixation element through the boneplate into the circumferential rim substantially along a medialdirection; and driving at least one second fixation element through thebone plate and into a respective one of the inferior pole and thesuperior pole.
 2. The method as recited in claim 1, further comprising,after the creating step and before the inserting step, the step ofperforming a lateral parapatellar arthrotomy.
 3. The method as recitedin claim 2, further comprising the step of angulating the patella so asto gain direct visual access of an articular surface of the patella. 4.The method as recited in claim 3, wherein the step of angulating isperformed prior to the step of driving at least one lateral fixationelement. 6-23. (canceled)
 24. The method as recited in claim 3, whereinthe step of driving the at least one second fixation element comprisingthe step of driving at least one superior fixation element through thebone plate and into a superior pole of the patella in asuperior-to-inferior direction, so as to fix the bone plate to thesuperior pole.
 25. The method as recited in claim 24, wherein the stepof driving the at least one superior fixation element compresses thebone plate against the superior pole of the patella, and further causesthe at least one superior fixation element to threadedly purchase withcortical bone at the superior pole.
 26. The method as recited in claim24, wherein the step of driving the at least one second fixation elementfurther comprises the step of driving at least one inferior fixationelement through the bone plate and into an inferior pole of the patellain an inferior-to-superior direction, so as to fix the bone plate to theinferior pole.
 27. The method as recited in claim 26, wherein the stepof driving the at least one inferior fixation element further comprisesthreadedly purchasing the at least one inferior fixation element incortical bone of the superior pole.
 28. The method as recited in claim26, wherein the step of driving the at least one inferior fixationelement comprises the step of threadedly mating a head of the at leastone inferior fixation element to the plate.
 29. The method as recited inclaim 26, further comprising the step of directly visually inspectingthe articular surface during at least one of the driving steps.
 30. Themethod as recited in claim 26, further comprising the step of passing atleast one suture between the second portion of the plate and thepatella, switching the suture into a patellar tendon that is attached tothe patella, and attaching the at least one suture to the bone plate.31. The method as recited in claim 1, further comprising the step ofdriving an anterior fixation member through a second portion of the boneplate and into an anterior surface of the patella, wherein the secondportion of the bone plate faces the anterior surface.
 32. A bone plateconfigured for patella fixation, the bone plate comprising: a bone platebody defining an inner surface configured to face the patella, and anouter surface opposite the inner surface, the bone plate body including:i) a base configured to surround a lateral portion of a circumferentialrim of the patella, the base including an intermediate section, a firstouter section that extends substantially in a first select longitudinaldirection from the intermediate section, and a second outer section thatextends from the intermediate section substantially in a second selectlongitudinal direction opposite the first longitudinal direction; andii) an outer portion that extends from the base in a first selectlateral direction substantially perpendicular to each of the first andsecond select longitudinal directions, wherein each of the intermediatesection, the first outer section, the second outer section, and theouter portion defines a respective at least one bone fixation hole thatextends through the bone plate body from the outer surface to the innersurface.
 33. The bone plate as recited in claim 32, wherein the basecomprises at least one row of eyelets that is oriented along alongitudinal direction that includes the first select longitudinaldirection and the second select longitudinal direction.
 34. The boneplate as recited in claim 33, wherein the at least one row defines afirst longitudinal end at the first outer section of the base, a secondlongitudinal end at the second outer section of the base, and a middlesegment at the intermediate section of the base, each of the firstlongitudinal end, the second longitudinal end, and the middle segmentdefining at least one respective bone fixation hole.
 35. The bone plateas recited in claim 34, wherein the outer portion comprises at least onecolumn that extends from the at least one row in the first selectlateral direction, the outer portion defining a first lateral end thatextends from the at least one row, a second free lateral end, and amiddle segment that extends between the first and second lateral ends.36. The bone plate as recited in claim 35, wherein the at least onecolumn comprises first and second columns, and a cross-beam that extendsfrom the first column to the second column.
 37. The bone plate asrecited in claim 36, wherein the first and second outer sections of thebase are defined by respective eyelets that are disposed outboard of theeyelets of the outer portion along the longitudinal direction, and thefirst and second columns define outer boundaries of the outer portionwith respect to the first and second select longitudinal directions,respectively.
 38. The bone plate as recited in claim 32, wherein the atleast one bone fixation hole second portion of the bone plate isthreaded.
 39. The bone plate as recited in claim 38, wherein the atleast one bone fixation hole of the first portion of the bone plate isunthreaded.
 40. The bone plate as recited in claim 39, wherein the atleast one bone fixation hole of the intermediate section is unthreaded.41. A fixation system comprising: the bone plate as recited in claim 32;a plurality of fixation elements configured to extend through the boneplate and into the patella; and at least one suture configured to bestitched to a patellar tendon, passed between the outer portion and ananterior surface of the patella, and attached to the bone plate.